Chondral Disease of the Knee - part 7 pps

Advanced patellofemoral arthritis TREATMENT Patellofemoral arthroplasty SUBMITTED BY Tom Minas, MD, and Tim Bryant, RN, Cartilage Repair Center, Brigham and Women's Hospital, Chestnut

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Case 24 83

FIGURE C24.3 Posteroanterior 45-degree flexion weight-bearing (A) and lateral (B) radiograph obtained 14 months after allograft medial meniscus transplantation and revision ACL reconstruction

mattress sutures and seating of the posterior

bone plug into its recipient tunnel The anterior

horn was fixed into a blind tunnel at the

anatomic insertion of the native meniscus

inser-tion site Finally, the ACL was passed and

secured with a staple on the tibia and a Ugament

button on the femur due to slight graft

mis-match and partial compromise of the posterior

cortex of the femur (Figure C24.2D,E)

Postop-erative rehabilitation was guided primarily by

the ACL protocol except for restriction of

weight bearing beyond 90 degrees of knee

flexion for the first 6 weeks Return to

unre-stricted activities was permitted at 6 months

FOLLOW-UP

At 18 months, the patient had full range of

motion, denied any medial-sided knee pain, and

had no complaints of instability He had a grade

I Lachman examination with a firm endpoint

and a negligible pivot shift Radiographs

demonstrated excellent positioning of the ACL

graft and proper seating of the meniscus

trans-plant bone plugs No evidence of joint space

narrowing was present (Figure C24.3) Repeat KT-2000 evaluation revealed a 2-mm side-to-side difference on maximum manual testing The patient recently returned to participating

in competitive soccer

DECISION-MAKING FACTORS

1 Young, high-demand patient with ipsilateral symptoms related to a prior subtotal menis-cectomy with a chief complaint of pain and instabiUty

2 Loss of the primary (ACL) and secondary (posterior horn of the medial meniscus) restraints to anterior translation of the left knee

3 Intact articular cartilage

4 A relative contraindication to performing

an isolated medial meniscus transplant without ACL reconstruction Similarly, revi-sion ACL reconstruction without improving the secondary restraints for anterior tibial translation may place the newly recon-structed ACL at continued risk for prema-ture failure

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Advanced patellofemoral arthritis

TREATMENT

Patellofemoral arthroplasty

SUBMITTED BY

Tom Minas, MD, and Tim Bryant, RN, Cartilage Repair Center, Brigham and

Women's Hospital, Chestnut Hill, Massachusetts, USA

CHIEF COMPLAINT AND

HISTORY OF PRESENT ILLNESS

The patient is a 41-year-old man with a

long-standing history of anterior right knee pain As

a teenager he sustained a patellar dislocation

with an osteoarticular fracture An open VMO

quadriceps repair and removal of loose body

was performed Since then, five further

arthro-scopic debridements have been performed

Presently he complains of chronic right anterior

knee pain He uses antiinflammatories and ice

for pain management only He has pain that

awakens him at night when he rolls over in bed

He is able to walk better on level surfaces than

on inclines or up and down stairs Additionally,

he must use a handrail one step at a time to

ascend or descend the stairs He has frequent

activity-related effusions He requests a

defini-tive operation that will relieve him of his pain

and allow him to rapidly return to work to

support his family His job does not require

physical or labor-intensive activities

PHYSICAL EXAMINATION

Height, 6ft, lin.; weight, 2101b Clinical

exami-nation demonstrates a relatively fit 41-year-old

man with clinically neutral ahgnment He walks

with an antalgic gait He must use his hands to

get out of a seated position; he is unable to

crouch or squat His range of motion is from 0

to 125 degrees of flexion Other findings include severe patellofemoral crepitation, a large joint effusion, and a relatively normal quadriceps angle of 15 degrees His ligament and meniscal examination is unremarkable

RADIOGRAPHIC EVALUATION

Standing radiographs demonstrate a well-maintained tibiofemoral joint space Radi-ographs demonstrate a narrowed patello-femoral joint space (Figure C25.1)

SURGICAL INTERVENTION

At arthrotomy, the tibiofemoral articulations were intact The patellofemoral joint demon-strated severe erosive grade IV changes to the trochlea and the patella with a convex hypoplastic trochlea (Figure C25.2) A patellofemoral arthroplasty was performed (Figure C25.3) Postoperatively, the patient advanced readily to weight bearing and range

of motion as tolerated

FOLLOW-UP

Within 3 weeks of his patellofemoral prosthe-sis, the patient was pain free and returned to work Two years after implantation, he remains satisfied with the result

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Case 25 85

FIGURE C25.1 Preoperative plain standing anteroposterior (A) and skyline (B) radiographs demonstrate normal tibiofemoral joint space with central and lateral patellofemoral compartment joint space narrowing

FIGURE C25.2 Appearance at the time of open

arthrotomy The trochlea is convex, hypoplastic, and

has severe erosive changes Similarly, the patella has

a large area of exposed bone and has a dysplastic concave appearance

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FIGURE C25.3 Postoperative plain lateral (A), anteroposterior (B), and skyline (C) radiographs demonstrate inset trochlear cobalt-chrome prosthe-sis and onset patellar polyethylene prostheprosthe-sis

1 Advanced, highly symptomatic, isolated

patellofemoral arthritis unresponsive to

prior efforts at debridement and

conserva-tive management

2 Disease extent poses a highly guarded

prognosis for autologous chondrocyte

implantation (ACI) Although

osteochon-dral allograft remains a viable treatment

option, it also carries a more guarded

prog-nosis, and the patient is unwilling to undergo

the prolonged rehabilitation required of this cartilage transplantation procedure

A willingness to maintain relatively reduced activity levels to maximize the longevity of patellofemoral arthroplasty The patient desires a predictable outcome and has low-demand requirements

Informed consent that should the patellofemoral arthroplasty fail, revision to total knee arthroplasty is unHkely to be compromised

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PATHOLOGY

Multiple chondral defects

TREATMENT

Autologous chondrocyte implantation of the trochlea and medial and lateral

femoral condyles

SUBMITTED BY

Jack Farr, MD, Cartilage Restoration Center of Indiana, Ortholndy,

Indi-anapolis, Indiana, USA

CHIEF COMPLAINT AND

HISTORY OF PRESENT ILLNESS

This patient is a 43-year-old man with a 10-year

history of lateral- greater than medial-sided

knee pain as well as anterior knee pain He

complains of catching and effusions in his right

knee At the time of evaluation, he provided a

history of having undergone arthroscopic

treat-ment previously that provided minimal relief of

his symptoms The patient works as a full-time

firefighter and complained of difficulty

per-forming all his duties because of

activity-related pain His desire is to return to higher

levels of activity that he previously enjoyed,

including jogging and racquetball At the time

of initial presentation, he limited his activities

to golf and biking and had gained 401b during

the previous 2 years

Review of the operative record indicates that

6 years previously he underwent chondroplasty

and drilling of his femoral condyle A repeat

chondroplasty and drilling was performed 1

year before presentation Despite these

treat-ments, his symptoms recurred

with a slightly antalgic gait on the right He has

a trace effusion He has no gross atrophy His range of motion is 0 to 130 degrees on the right compared to 0 to 135 degrees on the left His ligament exam is unremarkable He has marked tenderness on the lateral joint line and, to a lesser degree, at the medial joint line and patellofemoral joint There are no mechanical signs, and patellar tracking is normal

RADIOGRAPHIC EVALUATION Weight-bearing anteroposterior and lateral radiographs show slight medial joint space nar-rowing and ossification changes in the lateral femoral condyle (due to prior drilling) (Figure C26.1).The Merchant view shows the patella to

be centrally located His long-leg alignment views show only 2 degrees of varus compared

to the contralateral side His magnetic reso-nance image (MRI) is consistent with a chronic osteochondritis dissecans of the lateral femoral condyle and chondrosis of the medial and patellofemoral compartments

Height, 5 ft, 9 in.; weight, 2281b The patient

stands in slight varus alignment compared to

neutral on the contralateral hmb He ambulates

At the time of staging arthroscopy and biopsy for autologous chondrocyte implantation (ACI), grade IV chondrosis was noted at the

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trochlea (2.0cm by 3.0cm), medial (1.5cm by

2.0 cm), and lateral (1.2 cm by 1.1cm) femoral

condyles (Figure C26.2) These lesions were

contained The opposing articular cartilage was

intact At the time of definitive treatment, ACI

was performed for all three lesions (Figure

C26.3) No realignment was performed

FIGURE C26.2 At index arthroscopy, lesions of the (A) medial femoral condyle, (B) trochlea, and (C) lateral femoral condyle are visualized

FIGURE C26.1 Anteroposterior (A) and lateral

(B) radiographs demonstrate maintenance of joint

spaces

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Case 26 89

A DRB

FIGURE C26.3 Autologous chondrocyte

implanta-tion (ACI) periosteal patches in place: (A) medial

and lateral femoral condyles and (B) trochlea

Postoperatively, the patient was made

pro-tected weight bearing with crutches for 6 weeks

and utilized continuous passive motion for 3

weeks initially with restricted motion The

patient slowly advanced to full, unrestricted

activities by 18 months

FOLLOW-UP

The patient had returned to high-level activities

including full-time firefiighting Second-look

arthroscopy 3 years following the implantation

revealed excellent fill and marginal integration

of all defects (Figure C26.4)

FIGURE C26.4 Second-look arthroscopy demon-strates excellent fill and marginal integration of (A) trochlea, (B) medial femoral condyle, and (C) lateral femoral condyle

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1 Active patient with multiple focal chondral

defects with limited alternatives to ACI,

especially because of the concomitant

symp-tomatic trochlear defect

2 Despite a mild varus deformity, the presence

of lateral compartment disease led to the

decision to avoid osteotomy

3 Shallow osteochondral lesion of the lateral femoral condyle amenable to single-stage ACI without bone grafting

4 Failure of two prior attempts at standard drilling and chondroplasty

5 Comphant patient willing to tolerate a prolonged rehabilitation period with a desire to return to high-level activities if possible

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PATHOLOGY

Traumatic patellar instability with focal chondral defect of the patella

TREATMENT

Autologous chondrocyte implantation of the patella with distal realignment

(Note that the use of ACI for the patella is considered off-label usage, but was

indicated and performed with explicit patient and family informed consent

and under the guidance of an Institutional Review Board protocol allowing

prospective study of this patient at the author's institution.)

SUBMITTED BY

Brian J Cole, MD, MBA, Rush Cartilage Restoration Center, Rush

Univer-sity Medical Center, Chicago, Illinois, USA

CHIEF COMPLAINT AND

HISTORY OF PRESENT

ILLNESS

The patient is a 17-year-old female who initially

presented with a 3-year history of left knee

problems She first injured her knee while

playing basketball when she dislocated her

patella She complains of anterior left knee

pain, giving-way, catching of the patellofemoral

joint, and residual symptoms consistent with

patellar instability Her symptoms have been

getting progressively worse She rates her

overall knee function as being poor and states

that before her injury her knee was nearly

normal Previously, she had undergone an

arthroscopy during which a small

osteochon-dral lesion of the patella was noted A L5-cm

loose body was found and removed The loose

piece was derived from the patella, leaving a

full-thickness cartilage lesion of the patella

approximately 1.5 cm in diameter with minimal

bone loss At the time of loose body removal, a

lateral release was performed She underwent

extensive physical therapy, emphasizing a

patellofemoral rehabilitation program Before

this injury, she was a very active adolescent girl participating in multiple sports at her school At the time of presentation, she was unable to par-ticipate in any sports because of her significant knee-related complaints

PHYSICAL EXAMINATION Height, 5 ft, 2 in.; weight, 1051b The patient ambulates with a nonantalgic gait She stands

in approximately 4 degrees of symmetric mechanical-axis valgus She has a mild bilateral pronation deformity of both hindfeet She has

a moderate-sized joint effusion She has signif-icant patellar apprehension with two-quadrant laxity medially and three-quadrant laxity later-ally There is no excessive patellar tilt or sub-luxation when measured passively She has a positive J sign and a Q angle of 10 degrees She has crepitus with active flexion and extension with an audible and palpable catching sensation

of the patella at approximately 45 degrees of flexion The medial and lateral joint lines are not painful Her ligament examination is within normal Hmits

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RADIOGRAPHIC EVALUATION

Plain radiographs revealed no significant

sub-chondral sclerosis or joint space narrowing, but

did reveal a definite central irregularity of the

patella best seen on the lateral view Merchant

views demonstrated the patella to be centered

within the trochlea There was no evidence

of trochlear hypoplasia Magnetic resonance

images demonstrate a central patellar chondral

defect with slight edema in the subchondral

bone in the region of the defect

SURGICAL INTERVENTION

The patient underwent her second left knee

arthroscopy during which a full-thickness

chon-dral defect was noted in the central aspect of

the patella measuring approximately 16 mm by

16 mm (Figure C27.1) At the same time, an

articular cartilage biopsy was performed with

the intention to perform autologous

chondro-cyte implantation (ACI) of the patella within 3

months of this intervention

Approximately 10 weeks later, the patient

underwent ACI through a lateral arthrotomy FIGURE 0212 Intraoperative photographs at the

time of autologous chondrocyte implantation proce-dure Patellar lesion before (A) and after (B) the periosteal patch is sewn in place

FIGURE C27.1 Arthroscopic photograph reveals

full-thickness chondral defect of the patella

measur-ing approximately 16 mm by 16 mm in diameter

centered over the lateral retinaculum (Figure C27.2) A concomitant distal realignment pro-cedure was also performed (Figure C27.3).The patellar defect was essentially central and cir-cular, measuring 16 mm by 16 mm with minimal bony involvement Postoperatively, she was made heel-touch weight bearing for approxi-mately 6 weeks until radiographs demonstrated evidence of healing of the distal realignment Although she was allowed to flex her knee daily

to 90 degrees, continuous passive motion was restricted to 45 to 60 degrees of flexion during its use for the first 6 postoperative weeks She advanced through the traditional rehabilitation protocol for ACI of the pateUa She was asked

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